Identification of core competencies for exercise oncology professionals: A Delphi study of United States and Australian participants

Abstract Introduction Integration of exercise into standard oncology care requires a highly skilled workforce of exercise professionals; however, competency requirements have not kept pace with advancements in the field. Therefore, the aim of this study was to obtain consensus on core competencies required for an exercise professional to be qualified to work with adults undergoing active cancer treatment. Materials and Methods A three‐round modified electronic Delphi process was used. In Round 1, an international group of 64 exercise oncology stakeholders (i.e., exercise oncology professionals (n = 29), clinical referrers (n = 21), and people with lived experience (n = 14)) responded to open‐ended prompts eliciting perspectives regarding competencies needed for an exercise oncology professional to work with adults receiving active cancer treatment. Subsequently, only exercise oncology professionals participated, ranking the importance of competencies. In Round 2, professionals received summary feedback, ranked new competencies generated from open‐ended responses, and reranked competencies not reaching consensus. In the final round, professionals finalized consensus ranking and rated frequency and mastery level for each. Results Consensus was reached on 103 core competencies required for exercise professionals to be qualified to deliver care to adults undergoing active cancer treatment. The core competencies represent 10 content areas and reflect the needs of clinical referrers and people with lived experience of receiving cancer treatment. Conclusions The core competencies identified reflect significant advancements in the field of exercise oncology. Results will underpin the development of education, certification, and employment requirements for exercise oncology professionals, providing a critical step toward achieving routine integration of exercise into standard oncology care.


| INTRODUCTION
Calls to integrate exercise into standard oncology care are being led by the United States (US) and Australia [1][2][3] to ensure all people living with and beyond cancer can access this evidence-based intervention shown to help manage multiple health-related side effects of cancer treatment. 4,5n the US, a 2018 Roundtable convened by the American College of Sports Medicine (ACSM) called for clinicians to incorporate exercise assessment, advice, and referrals as standard practice for people with cancer. 1 This call for integration was supported by a 2022 guideline from the American Society of Clinical Oncology (ASCO) stating oncology providers should recommend exercise during active treatment with curative intent. 2 In parallel, the Clinical Oncology Society of Australia (COSA) issued a position statement in 2018 calling on all healthcare professionals involved in the care of people with cancer to embed exercise as a standard component of cancer care.3 Despite these calls to action, exercise is not effectively translated into clinical practice: Data consistently suggest fewer than 15% of people diagnosed with cancer receive a referral to exercise during cancer treatment.[6][7][8] The Moving Through Cancer (MTC) task force, a multidisciplinary group of exercise oncology experts, summarized the complex issues underpinning this poor translation into five strategic priority areas to be addressed to achieve routine integration of exercise in cancer care by 2029.9 One identified priority was the need for a well-developed exercise workforce sufficiently competent in oncology.
Identifying exercise professionals competent in oncology is difficult for several reasons.University degrees, required for many roles, vary widely in their content, and specific training in oncology is minimal at best.Consequently, many exercise professionals seek additional oncology training, and many people look to ACSM for this training as the organization is the internationally recognized leader of exercise promotion and certification.There are two exercise oncology certifications that have been developed by or endorsed by ACSM (i.e., ACSM's Cancer Exercise Trainer (CET) certification & CanRehab); however, they were developed in 2008 and 2006, respectively and their supporting competencies have not been reviewed since inception.Therefore, these exemplar certifications are not reflective of the significant advancements made in the field over the past 15 years. 4,5,10urther, more than 20 exercise oncology certifications have emerged since ACSM's CET and CanRehab certifications were developed, and these newer certifications vary widely in content, delivery methods, and requirements.Additionally, many professionals gain skills on-the-job as real-world opportunities for exercise oncology professionals have become more available.The resulting exercise oncology workforce is comprised of a wide range of professionals with disparate skill sets that are difficult to quantify.This heterogeneity makes it hard to enact the practice and policy changes needed to support translation into clinical care, such as third-party payer reimbursement for qualified exercise professionals.
As efforts continue to push for the establishment of routine integration of exercise into cancer care, there is a need to identify the core competencies required of the workforce capable of delivering this service.Therefore, the aim of this study was to obtain consensus on the knowledge, skills, and competencies (i.e., core competencies) for an exercise professional to be qualified to work with adults undergoing active cancer treatment.To achieve this, we followed a modified Delphi process that included an international panel of experts actively involved in exercise oncology services.Clarification of these competencies Results: Consensus was reached on 103 core competencies required for exercise professionals to be qualified to deliver care to adults undergoing active cancer treatment.The core competencies represent 10 content areas and reflect the needs of clinical referrers and people with lived experience of receiving cancer treatment.

Conclusions:
The core competencies identified reflect significant advancements in the field of exercise oncology.Results will underpin the development of education, certification, and employment requirements for exercise oncology professionals, providing a critical step toward achieving routine integration of exercise into standard oncology care.

K E Y W O R D S
competency, Delphi, exercise, oncology, professional development will underpin the development of future education, certification, and employment requirements for exercise professionals, representing a critical step to achieve routine integration into standard oncology care.

| MATERIALS AND METHODS
This manuscript was guided by Delphi reporting guidelines outlined by Spranger et al. to ensure all required information was captured. 11e conducted a modified electronic Delphi study using a mixed methods approach that included three iterative rounds of electronic surveys.3][14][15] Online administration enables group discussion from a geographically diverse set of participants while maintaining anonymity and removing potential for domination of the group's opinion by individuals with a strong voice. 16The work was led by the MTC task force.Ethical approval was provided by Edith Cowan University's Human Research Ethics Committee (ID: 2021-02658 KENNEDY).All individuals provided informed consent prior to participation.

| Participant recruitment
Experts from three stakeholder groups (i.e., exercise oncology professionals, clinical referrers, and people with lived experience of participating in exercise during cancer treatment) were identified using a purposive sampling approach. 17Recruitment was limited to those providing or receiving care in the US or Australia because these two countries have active calls for exercise integration; recruitment was driven through the MTC task force members' networks.An initial list of experts for each stakeholder group was generated according to the criteria below.Participant anonymity was retained throughout the process.

| Exercise oncology professionals
Exercise professionals known to be actively working in a clinical oncology setting to provide exercise programming to people on active cancer treatment were invited to participate.Invitees included people trained to prescribe exercise for people with chronic conditions (i.e., exercise physiologists, cancer exercise trainers) and licensed practitioners trained to improve a person's mobility and function, and/or restore optimal health to return to important activities of life (i.e., physical therapists/physiotherapists, occupational therapists).People whose experience was limited to research settings were excluded.Exercise oncology professionals were asked to complete all three rounds of the study as they are the only group with expertise to critically evaluate day-to-day competency requirements.An initial email invitation was sent, followed by a reminder approximately 3 weeks later.Invitations for the second and third rounds were sent approximately eight and 12 months after completion of the Round 1 survey.A nominal incentive was offered in the third-round invitation for completion of the final survey.Participants who did not complete a given round were not invited into subsequent rounds.

| Clinical referrers
Clinicians known to actively provide exercise referrals to people receiving cancer treatment were invited to inform the competency development.The requirement to actively refer ensured participants could share a personal perspective about exercise oncology referrals.Clinical referrers were asked to participate in Part I of the Round 1 survey only, as they do not have the expertise to comprehensively assess the scope of work required by an exercise oncology professional.An initial email invitation was sent to identified experts.One reminder email was sent to nonrespondents 3 weeks later with no further contact.

| People with lived experience
People who participated in an exercise program while receiving cancer treatment were invited to inform competency development.They were asked to complete Part I of the Round 1 survey only as they do not have the expertise to comprehensively assess the scope of work required by an exercise oncology professional.In addition to referrals from the MTC task force, the exercise oncology professionals invited into the study were asked to invite potential participants for this group from their client list using an invitation email created by the study team.

| Survey design
The survey was designed to confirm consensus across three rounds.There is no set standard for how to determine consensus in literature. 18A priori, consensus was set at ≥90% (summing both "absolutely essential" and "very important") of respondents for each item.This high level of agreement was chosen because of the large volume of items and desire to focus only on the most crucial competencies while accounting for some variation in opinion.Each item was presented a maximum of two times.Proposed items that did not reach consensus the first time were represented for forced consensus (yes/no).Items that did not meet criteria to move forward on this subsequent round were removed.
2.2.1 | Round 1 survey: establishing agreement with existing competencies and brainstorming new ideas The Round 1 survey contained two parts.

| Part I
Participants' demographic and professional background information was confirmed, and then their personal reflections on the knowledge, skills, and abilities required for exercise oncology professionals were elicited through openended questions to brainstorm ideas without bias. 19The Round 1 survey can be viewed in Supplemental File S1.

| Part II
Ninety-one competencies described across two internationally recognized exercise oncology certification programs commonly used in the field (i.e., ACSM-CET and CanRehab) were presented.The list resulted from comparing the original ACSM-CET (n = 79) and CanRehab (n = 31) competencies and removing duplicates.The resulting 91 competencies were presented across nine categories defined by ACSM (Table 4).Participants rated the level of importance of each competency using a 5-point Likert scale ("absolutely essential", "very important", "of average importance", "of little importance", "not important at all").Participants were also provided the option of "I'm not sure" for each statement.After rating each competency in a category, experts were asked whether the whole category should be required (yes/no) and to add any competencies that were not captured by the existing list.
2.4.1 | Round 2 survey: clarifying responses and establishing agreement with newly developed competencies A description of overall key themes from Round 1 was summarized, and all competencies that achieved predefined consensus (≥90%) in Round 1 were presented at the beginning of each survey category.Competencies that did not achieve ≥90% agreement were represented with results of their consensus outcomes from Round 1; experts were asked to rate their agreement for inclusion (yes/ no).For whole categories that did not reach predefined consensus, experts were asked to rate their agreement with whether the category and each of the competencies within it should remain included (yes/no).Finally, new competencies and categories generated in Round 1 were presented for experts to rate their level of importance according to a 4-point Likert scale.The "not important at all" option was removed in this round based on the findings from Round 1.The Round 2 survey can be viewed in Supplemental File S2.
2.4.2 | Round 3 survey: final consensus and frequency/mastery All competencies that achieved predefined consensus (≥90%) in Rounds 1 and 2 were presented with a summary of previous results, and experts were asked to rate how often each competency was used in practice (i.e., frequency) and what level of skill each required (i.e., mastery) according to a 4-point Likert scale.Frequency options ranged from "rarely (less than monthly)" to "very frequently (daily)"; mastery options ranged from "advanced beginner skill" to "expert skill."The option to select "I'm not sure" was provided for each.Competencies introduced in Round 2 that reached near consensus (80%-89%) were represented, and experts were asked to rate their agreement for inclusion (yes/no), as well as rate frequency and level of mastery for each.Competencies that did not reach consensus of at least 80% when introduced in Round 2 were removed to reduce participant burden based on the experience of Round 1 and 2 results.The Round 3 survey can be viewed in Supplemental File S3.
The process to reach the core competencies is outlined in Figure 1.

Frequency of Likert scale responses was calculated (SPSS for Mac, version 29). Two reviewers (MK and KW) independently assessed open-ended responses provided in
Round 1 to determine alignment with existing competencies (yes/no).Open-ended responses determined to align were coded as duplicates and removed from further analysis.Responses presenting new content were inductively coded, grouped according to common themes, then aligned with an appropriate ACSM category for evaluation in subsequent rounds.New categories were created for responses that did not fit within an existing one.A F I G U R E 1 Flow diagram of the process of identifying core competencies for exercise oncology professionals.*One new competency suggested a change to an existing competency and was not counted as a unique competency.
*one new competency suggested a change to an existing competency and was not counted as a unique competency

Competencies achieving near consensus
15 competencies achieved consensus (>80%) and were sent back in round 3 to be re-ranked

Competencies not retained
for round 3 44 competencies did not achieve consensus (>90%) after being re-ranked from round 1 or did not achieve at least 80% consensus on first ranking

Exercise oncology professionals (n=24)
12 Australia; 12 USA Each competency was rated for frequency of use and level of mastery required to perform:

Competencies achieving consensus 14 competencies achieved consensus (>90%)
103* unique core competencies identified for exercise oncology professionals third reviewer (CM) was brought in to offer an alternative viewpoint and review all responses as a form of member checking.Every decision underwent thorough discussion.In instances where the initial two reviewers disagreed, the third reviewer offered fresh insight to facilitate the resolution of all coding decisions.

| Personal reflections
The open-ended personal reflection questions generated 446 participant responses, resulting in 58 new items for consideration (Table 4).Most of the new competencies (n = 47; 81%) aligned with an existing ACSM category.A new category was created (personal skills & attributes) for the remaining competencies.Twenty responses described components of an ideal program structure.They were removed from further analysis as they were not specific to a professional's abilities and considered out of the scope of the project.

| Round 1, Part II
Twenty-nine exercise oncology professionals completed Part II of the Round 1 survey.Six of the nine (67%) categories and 51 of the 91 (56%) competencies achieved consensus.Round 1 results are reported in Supplemental File S4.

| Round 2
Twenty-five exercise oncology professionals completed Round 2 (86% participant retention).Two of the three (67%) categories and 7 of the 40 (18%) competencies that were reranked achieved consensus.The one new category and 29 of the 58 (50%) new competencies achieved

| Round 3
Twenty-four exercise oncology professionals completed Round 3 (83% participant retention from Round 1; 96% from Round 2).Fourteen of the 15 (93%) competencies that were reranked achieved consensus resulting in a total of 103 items for inclusion in the final set of core competencies.Of these, the majority were rated as being performed frequently or very frequently (75%) and requiring a proficient or expert level of mastery (83%).A summary of Round 3 results is provided in Table 4; complete results are reported in Supplemental File S4.

| DISCUSSION
Integration of exercise into standard oncology care requires a highly skilled workforce of exercise professionals; however, competencies requirements for this workforce have not kept pace with advancements in the field.The resultant qualification requirements for professional practice remain unclear.This study used a modified Delphi process to gain consensus for the core competencies required for exercise professionals to be able to work with adults undergoing active cancer treatment.A total of 149 competencies were ranked across three survey rounds over a 12-month period.Consensus for 103 core competencies was achieved.These competencies will underpin the development of future education, certification, and professional practice requirements for exercise professionals to move toward widespread integration into standard oncology care.
The core competencies identified in this study reflect a maturation of the field of exercise oncology in the 15+ years since existing certifications were created by ACSM and CanRehab.Nearly half (n = 43) of the final 103 competencies were new suggestions from the panel of experts.Further, 67% (n = 30) of the 45 competencies not achieving consensus came from the original ACSM and/ or CanRehab list.This shift reflects our evolving understanding and acceptance of the role exercise during cancer treatment.The literature available for the first iteration of exercise oncology guidelines largely examined the safety, feasibility, and efficacy of exercise. 5,20In 2018, when the literature was rereviewed, 4,5 the exponential growth in high-quality research across the field allowed for the provision of specific exercise prescription guidance.Practical application of exercise oncology research in clinical practice also increased during this time as oncology clinicians and people who have received a cancer diagnosis have begun to recognize the benefits exercise provides. 6,21he study supports the need for workforce training to be exercise specific.Consensus was low for competencies that described context-dependent skills (e.g., working with a medical record), skills not directly related to exercise (e.g., sun exposure, nutrition), very specialized skills (e.g., lead balance exercises), and skills related to general program administration.This shift toward exercisefocused competencies reflects the movement toward multi-disciplinary care teams allowing for each professional to remain highly specialized. 22hile most (81%) of the 58 newly generated competencies aligned with an existing ACSM category, one new category was developed (personal skills & attributes).This new category primarily describes skills required to care for people based on their personal needs and preferences, not simply the requirements of their condition. 23This person-centered approach to care is the recommended model of cancer care across disciplines. 24Consensus to recognize skills such as "ability to empathize with patients" and "demonstrate patience in approach to a patient's needs" as core competencies in exercise oncology demonstrates professionals' alignment with delivery of best practice cancer care.
Personal reflections from clinical referrers and people with lived experience of exercising during cancer treatment offered important implementation considerations for the future of the exercise oncology certification processes.Clinical referrers' input focused on the need for trust in the exercise professionals abilities (e.g., good reputation, qualified, experienced).This is unsurprising based on the "trust gap" that limits referrals between clinicians and exercise professionals 25 ; however, it emphasizes the need for standardization of exercise oncology credentialing.Feedback from those with lived experience highlights a potential need for a practicum component to be included in the certification process.Their comments strongly aligned with the human behavior and counseling category, which includes skills that require an exercise professional to extend beyond book knowledge.Incorporation of a requirement for the demonstration of practical skills may also increase the validity of the certification among clinicians.The field of health coaching offers an exemplar for this certification approach. 26his study used a recognized expert consensus building process, inclusive of international and multiple stakeholder perspectives, to identify competencies for the exercise oncology workforce.However, there are limitations in its design.First, as there is no standard definition of a modified Delphi approach, 18 the decision to force agreement across treatment.research should investigate how to create a stepped certification program to reflect the skill sets required for delivering exercise programming to people at different stages of the cancer continuum. 27,28n conclusion, widespread agreement about the required competencies for exercise oncology professionals will allow for the creation of new training models and propel parallel initiatives required to achieve integration into standard oncology care. 9For example, in the US, while physical therapists can receive third-party reimbursement for their services, other exercise professionals cannot.There are currently not enough oncology-trained physical therapists to meet patient demand.Further, the current payment methodology for physical therapist services aligns with an impairment model of rehabilitation, which may limit wellness-focused exercise interventions.The workforce capable of billing for their services needs to be expanded to ensure a cost-effective solution to meet patient demand.The establishment of standardized competencies will help to streamline the skillset that can be expected from exercise professionals with an oncology "certification."This standardization will facilitate policy change efforts to enable all exercise oncology professionals to receive third-party payer reimbursement.The credentialing process for Accredited Exercise Physiologists (AEP) in Australia provides an exemplar for a standardized credential that has achieved government support. 29While work needs to be done to optimize the integration of AEPs into the Australian Medicare system, the national standardization of the AEP credential facilitates a clear understanding of the minimum training and competency level that can be expected of all exercise professionals in the country.Further, while current training programs for both physical therapists and exercise physiologists include some of the 103 core competencies described in this study, neither covers all.To embed exercise into standard oncology care, the workforce-inclusive of all exercise professionals and physical therapists-needs to be upskilled to be able to provide the high-quality care required of referring clinicians and expected by patients.This study represents a foundational step toward achieving that goal; however, future work needs to focus on the development of implementation strategies to promote the use of the identified competencies in all exercise oncology training and certification programs.
All stakeholder groups: prompted with open-ended questions to "brainstorm" knowledge, skills, and competencies required for exercise oncology professionals Part II Exercise oncology professionals only: rated each of the 91 competencies as absolutely essential, very important, of little importance, or not important at all Competencies not achieving consensus 40 competencies did not achieve consensus (<90%) or were included in a category that did not achieve consensus; sent back in round 2 to be re-ranked Characteristics of exercise oncology professionals.
T A B L E 1 Characteristics of people with lived experience.Complete list of included competencies.19.Ability to safely and appropriately progress exercise to ensure an appropriately intense exercise dose to stimulate desired adaptations while minimizing risk is important to ensure not only safety but also efficacy of exercise.Category 7: Program administration, quality assurance, and outcome assessment (consensus = 93%) 1.How to establish a safe and stimulating activity environment sensitive to the physical and psychological, confidentially needs of patients/clients with cancer including the appropriateness of group or individual therapies.Knowledge of the expected effects of treatment and their impact on patients' ability to exercise (i.e., when patients will feel well or unwell during a treatment cycle).Four items that reached consensus in this category distributed to other categories.Originally part of eliminated category = Category 4: Nutrition and weight management.
4,5 B L E 3 a Other includes colon and rectal, uterine, and lung.T A B L E 41. Ability to obtain a basic history regarding cancer diagnosis (e.g., type, stage) and treatment (e.g., surgeries, systemic, and targeted therapies).11.Ability to perform a subjective interview to understand patient's goals and patient burden of symptoms from cancer or cancer treatment.13.Ability to effectively review medical chart notes to understand cancer diagnosis (e.g., stage/grade of cancer) and treatments.9.Knowledge, skill, and ability to undertake appropriate ongoing screening in order to detect a change in condition and modify exercise prescription/program based on type of current therapies (e.g., no swimming during radiation).18.Knowledge, skill, and ability to undertake appropriate ongoing screening in order to detect a change in condition and modify exercise prescription/program based on individuals that may be at increased risk for adverse late effects that could increase risks associated with exercise (e.g., heart failure).threeroundswasmade to reduce participant burden because of the large number of items to be assessed.Given the high level of agreement, it is unlikely results would have been significantly different with additional rounds.Next, the study included experts from only two countries.While methods of program delivery vary across countries, the guidelines for exercise oncology professionals are internationally accepted.4,5Finally,these competencies reflect the highest level of care necessary, as the study specifically asked about working with adults actively receiving cancer a Musculoskeletal incorporated to this item.b c T A B L E 4 (Continued)